Wiki Is e/m billable

[cwilson3333]

The doctor's recorder broke, could not finish dictation. He had to be out of office for
several days after that. When he returned to complete dictation the charts that he was unable to finish, his documentation was very brief. Can this office visit be billed according to documentation:


Patient returns for follow up of fractured wrist.
Cast was removed.
Xrays look good.

[I am billing itemized vs global]

Is this permissable....99211
73100

[Also noted in the patient's record, is the fact that the recorder was broken on this date]

 

[johnmeyer]

Playing the devil's advocate....

I'm not sure. I would have to say that he's going to have to add more information for that x-ray. I bet you won't get the correct re-embursement as the insurance company will probably say you should have billed a 73100-26 since there's nothing stating the x-ray was taken at your facility.